Shared decision making from reintegration professionals' perspectives to support return to work: a qualitative study
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Vooijs et al. BMC Public Health (2021) 21:325
https://doi.org/10.1186/s12889-021-10365-z
RESEARCH ARTICLE Open Access
Shared decision making from reintegration
professionals’ perspectives to support
return to work: a qualitative study
Marloes Vooijs* , Nicole M. C. van Kesteren, Astrid M. Hazelzet and Wilma Otten
Abstract
Background: Work participation is an important determinant of public health; being unemployed leads to a
decrease in an individual’s health. In the Netherlands, people with a work disability can apply for disability benefits,
in which people also receive support to return to work (RTW). A method, currently used in the medical sector, that
can include both the perspective of the reintegration professional and of the individual in the process of RTW, is
shared decision making (SDM). In this article we explore to what extent reintegration professionals currently use
SDM, and to what extent they prefer to use SDM in their ideal interaction with clients.
Methods: We performed semi-structured interviews with fourteen reintegration professionals from four different
municipalities. The transcripts were coded according to content analysis, applying open and axial coding.
Results: Reintegration professionals emphasised the importance of having a good relationship with clients, of
building trust and collaborating as a team. They did not inform their clients that they could be part of the decision-
making process, or discussed a shared goal. Although professionals did emphasise the importance of aligning their
approach with the preferences of the client and though they tried to offer some choice options, they did not
mention available options, discussed the pros and cons of these options or evaluated decisions with their clients.
Furthermore, they did not mention any of these aspects in their ideal interaction with clients.
Conclusions: SDM has a potential value, because all professionals underline the importance of having an alliance
with clients, collaborating as a team, and striving to align their approach with the preferences of the client.
However, professionals currently perform a limited set of SDM steps. Additional knowledge and skills are needed for
both reintegration professionals and municipalities so that professionals can consider and reflect on the value of
using SDM, or SDM steps, in supporting RTW. Providing clients with knowledge and skills seems necessary to
facilitate both self-management and SDM.
Keywords: Shared decision making, Patient participation, Autonomy, Evidence based, Employment, Employability,
Return to work
* Correspondence: marloes.vooijs@tno.nl
Netherlands Organisation for Applied Scientific Research TNO, Sustainable
Productivity and Employability, Leiden, The Netherlands
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data made available in this article, unless otherwise stated in a credit line to the data.Vooijs et al. BMC Public Health (2021) 21:325 Page 2 of 10 Background needs to be informed that he or she can be part of Although work participation is an important determin- the decision-making process, and the professional and ant of public health, many people are confronted with a the patient need to discuss the shared goal they want work disability [1–3]. People with a work disability face to achieve [18]. Secondly, the patient is informed unemployment twice as much as people without a dis- about all the available options to reach the shared ability [4, 5]. Unemployment leads to a decrease in goal and all the possible pros and cons of these op- health for these individuals, since work provides struc- tions are discussed, that is option talk [18]. Finally, in ture, social contacts, a sense of belonging and the feeling decision talk, the preferences for the various options of being part of society [6–8]. In addition, unemploy- are discussed and a shared decision is made, which ment greatly reduces the labour supply, which limits could also entail delegating the decision to the profes- economic growth for society as a whole [9]. sional [18]. In the Netherlands, people with a work disability The premise of SDM is that both the physician and can apply for disability benefits. The work disability the patient have unique and valuable information rele- policy is decentralised and delegated to the munici- vant to the decision; the physician provides evidence- palities in order to provide individuals, referred to as and experience-based knowledge, while the patient con- ‘clients’, with customised support [10]. In recent tributes his or her preferences and personal experiences years, most municipalities have shifted towards a [18, 19]. The use of SDM in doctor-patient relationships more support-oriented policy instead of a more results in greater satisfaction with the alliance between control-oriented policy, because it proved to be more physician and patient, higher levels of self-management effective in supporting individuals to return to work and autonomy, and greater compliance with the plan of (RTW) [11, 12]. To support clients, that is people action [16]; outcomes which could highly facilitate the who receive a disability benefit and being supported process of RTW. Therefore, in this article we want to towards RTW, many municipalities have pre- explore the research question whether reintegration pro- purchased re-integration interventions executed by a fessionals already use one or more of the SDM steps in re-integration organisation, such as schooling or their interaction with clients and to what extent, and training (e.g., learning Dutch language), empower- whether they would like to use one or more of these ment interventions, work placements to ‘learn’ the steps in their ideal interaction with clients in the future. client to work etc., which are deployed depending on a client’s situation [13]. Methods After the application for a disability benefit has been We performed semi-structured interviews with reinte- received, reintegration professionals in the work and in- gration professionals working for municipalities. Before come domain check and approve the issuance of this the start of the interviews, we developed an interview disability benefit (‘legal aspect’) and primarily support guide to answer the research question of this study (see the client toward RTW (‘goal-oriented’), adapted to his Supplementary Material), based on the three-talk model or her abilities [14]. Depending on the municipality, explaining SDM [18] and multiple work sessions with these functions are either executed by one reintegration the research team to formulate and structure the ques- professional so that he/she has the complete overview of tions. Features of the consolidated criteria for reported a client’s situation, or intentionally distributed among qualitative research (COREQ) [20] were used to improve two reintegration professionals as some municipalities the design and quality of reporting the present qualita- strongly believe that dividing the goal-oriented and the tive research and are addressed in this methods section legal aspect is more effective in building an alliance with (see Supplementary Material). The Medical Ethics Com- a client [15]. mittee of the Netherlands Organisation for Applied Sci- The decisions and actions in order for a client to entific Research TNO determined that no ethical RTW, like promoting an individual’s employability, approval was required for this study. greatly impact a client’s life. Therefore, it is important to include the client’s preferences in the decision- Participants making process [15–17]. A method to stimulate inclu- We recruited reintegration professionals. In the sion of the perspectives of both the professional and Netherlands, there is no specific training required to be- the client, is shared decision making (SDM) [15]. come a reintegration professional working at a munici- SDM originates from the medical sector and focuses pality. Most reintegration professionals have a on the three-talk model that contains three phases: background (i.e., study and/or work experience) in social ‘team talk’, ‘option talk’ and ‘decision talk’ [18]. work. The professionals were recruited using two strat- Firstly, in team talk a professional and the patient egies. In the first strategy we approached managers of must cooperate as a team, after which the patient the municipalities with whom we have already
Vooijs et al. BMC Public Health (2021) 21:325 Page 3 of 10
cooperated in projects to optimise the support of profes- they can be part of the decision-making process and dis-
sionals. We asked the managers if we could interview cussing shared goals), option talk (informing clients of
their professionals. After receiving the managers’ con- all available options, and the pros and cons of these op-
sent, we asked the managers to distribute information tions), and decision talk (discussing the preferences of
leaflets explaining the aim and content of the study both the professional and the client of the available op-
among the professionals. Professionals who indicated an tions and making a shared decision). We also focused on
interest in participating, were invited to send an email to the execution and evaluation of the decisions and pre-
the primary researcher (MV), providing their name, con- conditions of the use of SDM. We interviewed partici-
tact information and the municipality they work. In the pants until data saturation was reached.
second strategy we informed professionals at a national
conference, to which professionals of all municipalities Data analysis
were invited, of the possibility of participating in the The audio recordings of the interviews were transcribed
study. They too could apply by providing their name, verbatim. The transcripts were coded according to con-
contact information and the municipality they work for tent analysis, applying open and axial coding [22], using
in an e-mail to the primary researcher (MV), after which the Atlas.ti software program. Themes were derived
they were sent an information leaflet. We selected pro- from the interview guide, following the three-talk model
fessionals using consecutive- and voluntary sampling of Elwyn et al. [18]. The researchers MV and MaVi
[21], including professionals who are Dutch-speaking, coded one of the transcripts independently using open
had over 5 years of experience and provided current and coding, after which they discussed the codes until they
frequent support to clients to facilitate their RTW. We reached a consensus. MaVi then coded the remaining
also selected professionals from four different municipal- transcripts. Afterwards the retrieved open codes were
ities, since each municipality has its own approach to categorised into subjects and themes. The themes are
work participation. In two municipalities, the execution described in the results section. During the process, the
of the legal aspect and support to RTW was performed list of open, axial and selective codes was repeatedly
by two separate professionals, in which we spoke to the checked by the primary researcher (MV) and discussed
person facilitating the support to RTW. In the other two with the entire team to check the codes and reach a
municipalities, these functions were performed by one consensus.
professional. Municipalities subdivide clients (i.e. people
who receive a disability benefit and are supported to- Results
wards RTW) into client profiles, categorised according We conducted a total of fourteen interviews with reinte-
to the estimated time to RTW or how ‘work fit’ a client gration professionals from four different municipalities.
is. We took care to select professionals supporting cli- in our analysis, we found 19 subjects divided in seven
ents of all client groups; people who were not ‘work fit’ themes. We included quotes of the participating profes-
and had an estimated time to RTW of over two years, sionals to illustrate our findings.
ranging to people who were work fit and were estimated
that they could RTW right away. Team talk
Professional and client collaborating as a team
Data collection Most professionals roughly follow the same procedure
The semi-structured interviews with professionals were for new clients: first the intake, then guiding the client
conducted by telephone in November 2018 and had a towards being ‘work fit’, after which a client can RTW.
duration of an hour on average. The interviews with the The intake is where the professional and the client first
professionals were conducted by an experienced female meet and an overview of the client’s situation is estab-
researcher (MV, PhD) working in the occupational lished. Professionals all emphasised, especially in this
health field. Participants were informed that all informa- phase of the process, the importance of building an alli-
tion obtained prior or during the study would be han- ance with the client. One professional explained this by
dled confidentially and that an audio recording would be stating that “you have to build trust between each other”.
made. Prior to the interview, all participants were asked Professionals indicated that building a relationship and
to provide a verbal consent which was audio recorded. trusting each other is the foundation for support to-
During the semi-structured interviews with the profes- wards work participation. Building a relationship takes
sionals, we zoomed in on the different steps supporting time, but according to some professionals investing time
SDM in both their current interaction with their clients in a relationship from the start, will pay off later.
and their ideal interaction with their clients, specifically
team talk (having a safe relationship and the professional “In any case it is important to build a relationship
and client collaborating as a team, informing clients that with clients. It doesn’t even have to be because youVooijs et al. BMC Public Health (2021) 21:325 Page 4 of 10
want them to get a job, but this way you are in sorted, it becomes easy.” – Reintegration professional
touch more often. I think that helps.” – Reintegration (6).
professional (8).
Explaining to clients that they can be part of the process
A good relationship and trusting each other is indi- None of the interviewed professionals indicated that they
cated as a precondition for clients opening up about informed their clients that they can be part of the
their lives and” getting through” to the client, and decision-making process or recognised the need for this
have him/her provide a professional with information in their ideal interaction with clients. Most of the profes-
and insights into the client’s behaviour. By “getting sionals interpreted this question differently. For instance,
through to the client” some professionals meant: professionals responded that they explain their role as a
teaching clients to reflect on their actions towards professional to clients, and inform clients about their
work participation and on their wishes and prefer- legal obligations (e.g., clients must cooperate and accept
ences, and also, according to some professionals, to work offers whenever they can in order to receive their
gain a feasible perspective on work participation. monthly disability benefit). Some professionals even
Gaining insight into a client’s situation and learning interpreted the question of informing their clients, as
about the obstacles a client faces on the road to work informing other professionals about collaboration in-
participation, are important in making a good diagno- stead of collaborating with the client.
sis and planning follow-up actions. Professionals also
indicated that a good relationship increases both the “In any case I also try to explain my role in this, and
motivation of clients toward RTW and a willingness the reason it is important and why, what I inquire
to take action to reach that goal. from supervisors of clients and that, when it involves
benefits, they (clients) must know that they have
“Interviewer: So in fact you sort of guide people to- rights of course, but obligations as well, and what
ward gaining insight? Interviewee: Yes, that is right. those obligations are, and if that is something the cli-
It takes up a lot of time, you know? At least three ent can accept. Because I really want all that to be
hours of work, and more often than not they do not clear (to the client).” – Reintegration professional (7).
enjoy it much, because I ask them a lot of questions.
And they think, yes well, shouldn’t we get started Setting a shared goal
already (with actions to RTW)? I often have to ex- All professionals indicated that the goal of their support
plain, yes, but I have to know more about you before is the client’s RTW, as instructed by most municipalities.
I can really start helping you. OK, in the end they Professionals indicated that they strive to make clients
get it, but they do not like it, because they want this ‘work fit’, meaning that a client is ready to apply for a
problem solved as quickly as possible.” – Reintegra- job, followed by RTW. To achieve this goal, profes-
tion professional (14). sionals explained that they use a step-by-step approach.
They seem to formulate these steps themselves, but the
Professionals explained that they build relationships steps are not written down or shared with the client,
with clients by introducing themselves, using small talk, which limits SDM. Some professionals interpreted ‘set-
by making jokes and having a laugh, being informal in ting a shared goal together’ as ‘setting a shared goal with
their one-on-one communication and by having infor- colleagues’.
mal contact moments by app or e-mail to foster the rela-
tionship. Some professionals indicated that to establish a “I also often consult with other professionals. We will
good relationship you must approach a client as an equal get together and sometimes we will decide what to
partner. They label the relationship with their clients as do with a client and how we can approach it to-
“being a team” in which “you must have the same goal gether.” – Reintegration professional (8).
in mind”. One professional stated that “to be able to do
this work you have to be empathetic”. All professionals However, all professionals clearly endorsed the im-
stated that building a relationship is compatible with portance of involving the client in setting a shared goal
their ideal interaction with clients. and aim to align their approach with the client’s prefer-
ences. Some professionals were motivated by the idea
“I feel it is important to make contact first, to start a that the client is held accountable and should act on this
relationship with clients. Because you have to earn responsibility. Other professionals want clients to be
their trust, and vice-versa. I see it as a commitment, self-reliant, so that clients learn to have autonomy and
just like a marriage; it does not happen overnight. develop self-confidence in the choices they make. Profes-
You have to get to know them, and once that is sionals promoted self-management in clients by givingVooijs et al. BMC Public Health (2021) 21:325 Page 5 of 10
them homework to think about their RTW goals, which follows up on decisions before professionals opt to apply
could then be discussed in the next conversation. Many SDM.
professionals explained that if they “did not tailor the
job to the needs of the client, they would not obtain a “Well, when I think about working together with my
long-term solution for the client”. candidates, I think of it as facilitating. And what
that means is, let’s see what the candidate really
“I want the candidate to take the lead, for the candi- wants and see to what extent we can accommodate
date to have self-determination and to give her a him or her, and see what obstacles are blocking the
level of autonomy. So when I notice, especially in way and how I can remove them. And sometimes the
that area, that she could be a bit stronger, I will cer- problem lies with the candidate who will have to do
tainly try to cultivate that. So I try to encourage her something to remove those obstacles.” – Reintegra-
to make choices. ( …) “I’ll say, ‘think about what you tion professional (1).
would like to do and let’s discuss it’.” – Reintegration
professional (1). Option talk
Presenting choice options
In some cases, the preferences of the client and the Professionals indicated that asking about a client’s pref-
professional are in alignment. In other cases, clients have erences and goals, frequently results in various choice
different goals and ideas about their future work partici- options which professionals and clients can discuss. In
pation, or have unrealistic goals according to the profes- most cases, clients are asked to prepare a range of op-
sionals. In case of the latter, professionals indicated that tions before the meeting. A precondition for this discus-
they encourage clients to reflect on a more feasible per- sion, according to the professionals, is for the client to
spective. Another option would be that professionals provide feasible choice options. Furthermore, profes-
suggest what they believe is a feasible alternative in line sionals generally did not actively present different choice
with the preferences of the client. If that method is not options for a variety of reasons. The first reason being
an option, professionals then actively ask questions to the physical and mental limitations of clients, making it
obtain more information from the client in order to sug- difficult for professionals to match clients 1-on-1 with
gest an alternative option. available choice options, in most cases pre-purchased in-
terventions. Another reason, according to professionals,
“Many people want to get back to work and let you is that many clients lack the necessary level of autonomy
know ‘I want this and that’. And that is not possible, and self-management to discuss choice options. How-
because at this particular moment that is not feas- ever, there were also professionals who saw the possibil-
ible. Sometimes people do not understand why not. ity of presenting choice options regardless of the level of
So you want to start at the bottom of that ladder. self-management.
And you want to know what someone is capable of,
what someone does. What situation are they in? And “Sometimes their level (of self-management) is so low
once you know more, you start to figure out which that they cannot really see the consequences of their
approach might suit someone. ( …) And slowly build actions. That makes it more difficult to tackle this
to where you can say ‘why do you not go for a walk together, so I have to take more decisions. So with
outside?’ But you can also set targets with a client. some (clients) you go on this journey together, and
These can be baby steps, but, you know, with some discover what can be done and which steps we need
people that way is the only way”. – Reintegration to take to get there. And with others you might just
professional (10). say ‘these are the two steps available to you, which
one shall we pick?’ In that case, I make sure that the
Professionals reported several preconditions for setting choices are more limited and more concrete.” – Re-
a shared goal. Firstly, clients should have a certain level integration professional (5).
of autonomy and self-management. In other words, cli-
ents must be able to stand up for themselves and follow The third reason refers to the job descriptions of the
up on decisions. If clients are not autonomous, profes- professionals in the different municipalities. Some pro-
sionals opt for a more paternalistic style with clients, in fessionals explained that they “only perform intakes and
which professionals make all the decisions. Secondly, subsequently decide which re-integration intervention or
professionals state that SDM is only possible with clients trajectory is better suited to the client’s profile”. Then
motivated toward RTW and able to follow up on deci- they refer the client to a particular intervention or tra-
sions made. In summation, ideally a client must be as- jectory. Other professionals reflected on the division of
sertive, show initiative and demonstrate that he or she goal-oriented and the legal aspects of the job;Vooijs et al. BMC Public Health (2021) 21:325 Page 6 of 10
professionals who were only responsible for goal- Discussing pros and cons
oriented aspects of the job stated that they found it eas- None of the professionals reported on discussing the
ier to build a relationship with the client. They had the pros and cons of choice options with the clients. How-
idea that the client trusted them more, because they ever, professionals did report on having a preference for
were not responsible for checking if a client is entitled a choice option of their own, described as the” feasible
to benefits. perspective”. This feasible perspective is the result of an
estimate made by the professional, which seemed to be
“That is the advantage of not having to take that de- primarily an unconscious process of weighing the pros
cision (if a client is entitled to benefits). If I were to and cons while searching for a feasible option for the cli-
tell someone ‘if you do not show up, I will make sure ent, preferably in line with the wishes of the client as de-
you are penalised by a hundred per cent or I’ll have scribed in team talk. Factors influencing this weighing
your benefit revoked’, then I am the bogeyman. They process include the client’s preferences, obstacles the cli-
will never ever confide in me again.” – Reintegration ent faces (e.g. disabilities, housing conditions, presence
professional (11). of children), the amount of autonomy a client can han-
dle, if the client is able to reflect on his/her behaviour, if
A fourth reason is that the municipality has pre- the client shows initiative, and the client’s general and
purchased interventions that do not match clients’ pro- job- or sector-specific skills. The interaction with clients
files and lead toward RTW. Some professionals indicated described above is consistent with their ideal interaction
that in their ideal interaction with clients they would with a client.
have more autonomy in the choice options, meaning no
pre-purchased interventions and working demand- “What I try to do, is find out what will energise my
driven instead of supply-driven. As stated in team talk, clients, what are they passionate about. That is what
professionals emphasise the importance of aligning the I look for. For instance, that candidate would not
steps with the goals and preferences of clients. However, mind being a beautician … And if you keep digging
professionals experience this as a discrepancy between you might come up with something in a perfume
municipal policy and the support to RTW which profes- and cosmetics shop where she might be able to give
sionals provide. beauty tips to customers, that kind of thing. So pur-
sue that and the road you have to take starts to ap-
“In the organisation they focus on what people can pear, of what she might be able do over time … And
do physically and what their job profile is, previous that is how I keep peeling away until we come to a
work experiences, so they can be placed in a certain realistic, feasible perspective.” – Reintegration profes-
sector. For instance: ‘Someone is able to sit, so he or sional (1).
she can do production work, because that is done sit-
ting down.’ Instead we should be looking at what Decision talk
someone would really like to be doing and how we When we asked professionals whether they make shared
can enable that. Working with those job profiles I decisions, most professionals stated that they currently
think is the old way of working.” – Reintegration pro- make shared decisions with their clients during their
fessional (1). interaction, and that these shared decisions conform to
their ideal interaction with the client. However, follow-
Finally, some professionals mentioned that time and up remarks show that, although they want to involve the
training for themselves and their colleagues are precon- client in decisions, in the end they still make the
ditions to present choice options. Most professionals ex- decisions.
perience a high caseload allowing limited time per client.
Ideally, they prefer to have more time with clients to “I try doing it with a bit of indirect communication:
offer support of a higher quality and more SDM. you want to be a good father, don’t you? Yes. Don’t
you want to take care of your family? Yes. And don’t
“They expect our work to be tailored to clients’ you want to build a future for yourself? Yes. I said,
needs and that is important to clients and suits but then you will have to take steps to get there and
them best. Within the entire official system and one of those steps is taking good care of yourself and
all its legal rules and regulations. And still you of course you will be a good father.” – Reintegration
hope you help or counsel someone as best you professional (2).
can. Except, well, you just have to run production,
let’s be honest. You just have to handle request.” Some professionals even clearly indicated that “they
– Reintegration professional (7). have the final say”, mostly because they find that theyVooijs et al. BMC Public Health (2021) 21:325 Page 7 of 10
can make a better assessment of what is the most feas- clients. They also did not mention these aspects in their
ible perspective for their clients toward RTW. ideal interaction with clients. Preconditions mentioned
are either connected to the client, such as having motiv-
“We try as much as possible to do things in consult- ation and self-management, or to the organisation, such
ation. They can always come up with suggestions. as having choice options, having a reasonable caseload
But I make the decision.” – Reintegration profes- to apply SDM and reflecting on having to perform both
sional (2). goal-oriented and legal aspect of the job.
Trust, collaborating as a team, and having an alliance
In addition, all professionals indicated that to not all are expressed by professionals as essential elements of
clients are able to handle choices, because of their men- supporting a client toward RTW in this study. These are
tal limitations, cultural differences, low autonomy, low important steps, as emphasised in SDM literature [18],
self-reflection or lack of initiative. and also in literature focusing on supporting clients to-
ward RTW in general [12, 15]. Although found to be es-
“Sometimes their level is so low that they cannot sential, de Winter et al. [23] stated that most of the
really see the consequences of their actions. That municipalities in the Netherlands focus on checking en-
makes it more difficult to tackle this together, so I titlement to benefits, and fraud. This puts a damper on
have to take more decisions.” – Reintegration profes- trust, collaborating as a team and having an alliance, and
sional (5). as a result it limits SDM and the support of clients to-
ward RTW in general. This is emphasised by research
Execution and evaluation of decisions stating that control decreases intrinsic motivation, be-
Some professionals explained that clients do not always cause it fails to satisfy the basic needs of clients [24].
follow up on decisions made in previous conversations. This means that although professionals clearly mention
the necessity of building trust and collaborating to-
“He said: ‘I would really like to work.’ OK. In the gether, the policy of municipalities may counteract cli-
previous session he had made a CV. I said, I did not ents’ autonomy and intrinsic motivation. Municipalities
receive your CV yet, send me your CV. ‘Yes, all right.’ should therefore consider the effect of the legal aspect of
I was on holiday for a week, autumn half-term, no the job, and consider whether focusing on trust and col-
CV. So I sent him another message. ‘Where is your laboration (i.e., goal-oriented activities) is more effective
CV? I have not received it yet.’ And then you get this in achieving both SDM and the support of a client to-
whole story, well, my son had a fall and now he is in ward RTW in general.
a cast and, well, lah-di-dah, I have not had time Not all steps of SDM are performed. For a start, pro-
and do not pressure me.” – Reintegration profes- fessionals generally do not inform their clients that they
sional (2). can be part of the decision-making process or provide
the client information about the various choices and
Ideally, professionals would like clients to follow up on their pros and cons. This lack of raising awareness and
decisions made. Furthermore, none of the professionals providing information, limits a client’s self-management
reported on evaluating the decisions made (together) or [16] and their intrinsic motivation as well [24]. Although
asking for input of the client in this evaluation. professionals indicate self-management in clients as a
precondition for the use of SDM in this study, clients
Discussion are denied the opportunity to do so due to lack of infor-
In this article we explored whether and to what extent mation [16]; a vicious circle. Informing a client could be
reintegration professionals used SDM steps in their a crucial first step to break that circle. The medical sec-
interaction with clients and if they would like to use one tor offers various tools, such as decision aids, informa-
or more steps in their ideal interaction with their clients. tional websites and campaigns [25] that provide clients
Results show that reintegration professionals found it with the necessary knowledge and skills, facilitating the
very important to have a good relationship with clients, self-management in clients and the opportunity to dis-
to trust each other, and to work together as a team. cuss options, and SDM, applicable to both professionals
They did not inform their clients that they could be part and clients in this sector.
of the decision-making process or discussed a shared With regard to making a shared decision, professionals
goal. Although professionals did emphasise the import- clearly indicated the importance of aligning the ap-
ance of aligning their approach with the preferences of proach of the professionals with the preferences of cli-
the client and they tried to discuss some choice options, ents. Therefore, most professionals strive to ask the
they did not discuss all available options or the pros and client for his or her preferences before making a deci-
cons of these options, or evaluated decisions with their sion. They do so because they find that essential toVooijs et al. BMC Public Health (2021) 21:325 Page 8 of 10 motivate the client to take steps toward RTW. Research are underlined by de Winter et al. [23]; they explain that underlines this by explaining that a client’s intrinsic mo- how you treat the client determines how the clients will tivation can be an important facilitator to RTW [12], behave [29]. In addition, as some professionals indicated which can be increased by clients experiencing auton- that SDM is possible when adapted to the level of self- omy and feeling connected to the process [24], and is management of the client, professionals could explore achieved by collaborating with a client during the whether SDM or steps of SDM could be performed process. Although professionals state the importance of adapted to the level of self-management of clients. including a client’s preference in the decision, they do A limitation of this study is that we performed the in- not go so far as to actually make shared decisions; they terviews by telephone, which minimised the information express that they have the final say in the decision- from non-verbal behaviour. However, we elected this making process. We believe that by not only including a method to make it possible for more professionals to client’s preference in the decision, but actually making participate in the study, considering their large caseload shared decisions, intrinsic motivation of a client will in- and limited amount of time. Another limitation is that crease even more because of the increased autonomy of we approached professionals in municipalities that we a client in being part of the process [24]. This is also the already facilitated to optimise support for clients in their crucial difference with other available methods to facili- RTW. In addition to voluntary sampling, this means that tate support to RTW, such as supported employment or these professionals were most likely to be more moti- motivational interviewing [25, 26]. These methods strive vated to provide optimal guidance, and subsequently to involve the clients in the process, but differ in that SDM, but that they were also more likely to provide us they do not explicitly offer choice and that the client is with more information on the ideal and current use of not actually part of the decision making process and fa- SDM. Another limitation is that we did not include the cilitated to make a decision. perspectives of clients into this study, to reflect on the Several professionals explained that they feel limited in steps used in SDM. Future research is needed on these their choice and decision options due to the pre- perspectives and if clients recognize and prefer steps of purchased interventions of municipalities, and the muni- the SDM in the received support towards RTW. Future cipalities’ focus on professionals supporting RTW. In research is also needed to explore and acquire insight addition, a lack of evidence of the effectiveness of these into the experiences of both professionals and clients in pre-purchased interventions [12, 27] limits the discus- the use of SDM, to see which elements of the approach sion about the pros and cons of the options. In fact, in add value to both clients and professionals. Finally, al- the medical sector [28] the pros and cons are discussed though professionals state that they are willing and mo- based on scientific evidence, which facilitates choosing tivated to use SDM, increasing the knowledge and skills the appropriate option. To increase choice and decision of professionals seems needed [30–34] to raise their options, municipalities can explore whether these inter- awareness so they can reflect on the value of using SDM ventions are effective and for whom and when. This en- and the steps of SDM toward RTW. Also, providing cli- ables professionals to explain evidence-based pros and ents with information seems necessary to facilitate self- cons per intervention and per step toward RTW, and be management as a first step in increasing the applicability able to meet the needs of the individual client instead of of SDM. Future research should focus on how and what applying a supply-driven approach. knowledge and skills are needed for the use of SDM by Although professionals are willing and strive to imple- professionals and clients. ment SDM, professionals clearly state that SDM is not suitable for all clients; they state that SDM is only for Conclusions clients who are responsive and motivated, show initiative SDM has potential value in the process of RTW; profes- and follow-up on plans, in other words: self- sionals confirm the importance of building trust, collab- management. However, as discussed, professionals do orating as a team and aligning the approach with the not provide the information to build the knowledge and preferences of the client. However, professionals cur- skills needed for self-management and motivation. This rently perform a limited set of SDM steps. Professionals can lead to a self-fulfilling prophecy [16]. It implies that are not aware of all steps of SDM; steps which could be municipalities demand self-management in clients, but helpful in the process of RTW. Additional knowledge, do not provide sufficient resources to achieve this. It skills and tools are needed for both reintegration profes- could mean that there might be more clients who could sionals and municipalities so that professionals can con- be self-reliant and motivated if given sufficient informa- sider and reflect on the value of using SDM, or SDM tion and opportunity [16]. Finally, SDM would actually steps, in supporting RTW. Also providing clients with increase motivation, since the client has more autonomy knowledge, skills and tools seems necessary to facilitate in the decision-making process. Both of these reasons both self-management and SDM.
Vooijs et al. BMC Public Health (2021) 21:325 Page 9 of 10
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Funding 12. Blonk RWB. We zijn nog maar net begonnen. Rede Tilburg University. In:
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/ Dutch Ministry of Social Affairs and Employment). The funding body has https://www.arbeidsdeskundigen.nl/cms/files/2020-04/2.-180125-rede-
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The authors declare that they have no competing interests. der Burg S, van der Weijden T. Joint decision-making & self-management: A
literature study of the effectiveness and the conditions for success.
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